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*"."-•:_ti- �,�-=*n err,. f APPLICATION FOR PERMIT tttr SAN JOAQbi" LOCAL HEALTH :STRICT pp ! 1601 E. HAZELTON AVE., STOCKTON-, CA PFRMIT NO. Telephone (209) 466-6781 � DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the 'work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump j and the Rules a nd,Re�glul_attiions of the San Joaquin Local /Heeaalltth i ttjict. Job Address y 4 �-s t�[ r/y j d '� "aSuKTivision Name Owner's Name Address Address Phone Contractor's Name d .,T [ E License No. Phone TYPE OF WELL/PUMP WORK. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 016 r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELLTHER WELL PITS/SUMPS ( ' INTENDED U5E TYPE OF WELL PROBLEM AREA CONSTRUCTION _SPECIFICATIONS V 1 Industrial ❑ Open,Bottom ]Manteca Dia. of Well Excavation Domestic/Private ti L_f ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public } ❑Other ❑ Delta Type of Casing V Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth F R Depth of Grout Seal � e ❑Geophysical Type of Grout Other } Surface Seal Installed by Repair Work Done ❑ Type of Pump ! P. State Work Done Well Destruction ❑ Well Diameter q!-_ ,Sealing Material (top 50') _ Depth �° FiTler Material (Below 50' TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage .pit permitted if public sewer is p `'3 , '- available within 200 feet.) Ll 4 Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms —�s�-- Lot size _ _ Character of soil to a depth .feet:_ - ' _! War table depth SEPTIC TANK ® Type/Mfg rCapacity No. Compartments _ PKG. TREATMENT PLT. ❑ Type/Mfg Capacity ,¢ R Method of Disposal ' SEWAGE SYSTEM Distance. to nearest: Welles Foundation ' Property Line DESTRUCTION LEACHING LINE F ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ' 'l 1 Property Liner. SEEPAGE PITS ❑ Depth Size W" '`N` ,Number- + i. SUMPS Distance to nearest: Well Foundation Property Line .f r � DISPOSAL PONDS I hereby certify that I have prepared this application and that th_�wprk -will be -d6ne in accordance with San Joaquin-county ordinances, state laws, and rules'and regulations of the San Joaquin Local HealTh"Distr.ict: Home owner or licensed agent's signature'certifies the following: "I certify that in the performance of the workvfor which this permit is issued, I shall not employ any person in Such manner as to become subject to workman compensation '1•aws-of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work;for which this permit is issued, I shall employ persons subject to workman's compensation .laws of California." The applicant must ca 11 wired inspections. Complete drawing on reverse side. Signed X # Title: Date: I FOR'DEPARTMENT-USE 'ONLY s _ Application Accepted by Area ❑ Stk 466-6781 Additional Comments: 's ❑ Lodi 369-3621 Pit or Grout Inspection by ` Date ❑ Manteca 823-1104 A s Final Inspection by i Date � ❑ Tracy 835-6385 Applicant - Return all copi to: # Envirormental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CR 95201 FEE BASE AMOUNT pUE - AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. } q Fo— - ��;: NI; ;., 4 2-0 'S3 �3-a5 yEH�13-24 REV.-101$2 '" '""""' " .._, �A,_��. -- --r.�:. _ - R _ ,10/82,500 14-26